University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA FACTORS ASSOCIATED WITH UPTAKE OF INTERMITTENT PREVENTIVE TREATMENT FOR MALARIA IN PREGNANT WOMEN IN PRESTEA HUNI- VALLEY DISTRICT IN WESTERN REGION BY ELSIE KISSI-APPIAH (10637501) A DISSERTATION PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I do hereby declare that apart from the references made to other people's work which have been duly acknowledged, this dissertation is the result of my own research work done under supervision. I take full responsibility for this work. …………………………………… ………………………………. ELSIE KISSI-APPIAH DATE: (10637501) ……………………………………. ……………………………. DR. AGNES M. KOTOH DATE: (SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to Almighty God for the protection and strength, to my husband Mr. Kofi Owusu and children Freda, Theresa and Shadrach for their encouragement and support. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My gratitude goes to God Almighty for giving me life and strength to complete this work. I wish to express my profound gratitude to my academic supervisor, Dr. Agnes M. Kotoh, Department of Population, Family and Reproductive Health (PFRH), School of Public Health, University of Ghana. She consistently steered me in the right the direction whenever she thought needed it. I further extend my warmest gratitude to all the lectures and staff of PFRH School of Public Health, University of Ghana, for their support to my successful completion of the course. My sincerest gratitude goes to the staff of the Maternity unit at Prestea Government Hospital, Bogoso and Aboso Health Centres for their support in making this work a success. I would like to acknowledge all the respondents for their passionate participation. This accomplishment would not have been possible without them. Lastly, l appreciate the unfailing support, love and sacrifice of my husband, Mr. Kofi Owusu and my children, Freda, Theresa and Shadrach. Support received from other family members, Mama Theresa, Michael and Juliet cannot be glossed over. May God bless you. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background Individuals in endemic areas are susceptibility to malaria. Nevertheless, when women become pregnant mostly for the first time, they become more susceptibility to malaria. It is believed that malaria is the cause of persistent mild to severe anaemia, in spite of the fact that malaria in pregnancy may not be seen as a severe illness. In addition, low birth-weight of infants may be a cause of malaria in pregnancy. This happens when there is an obstruction with the maternal-fetal exchange that occurs at the placenta site. Ghana embraced a new Intermittent Preventive Treatment (IPT) using Sulphadoxine- Pyrimethamine (SP) policy in 2004, to prevent malaria in pregnancy. The coverage of IPTp-SP remains below the target (80%). The study intended to determine factors associated with IPT-SP uptake among pregnant women in the Prestea Huni-Valley. Methods This study employed cross-sectional design covered 333 pregnant mothers, 36 weeks of gestation and above, at Antenatal Care (ANC) in three health facilities. They were interviewed using a structured questionnaire in Prestea Huni-Valley District between May and June. Categorical variables were analysed as frequencies. Chi-square was used to measure the association between socio-demographic factors, practice at ANC on IPTp and knowledge on IPTp, and IPTp-SP use. The strengths of association were assessed using logistic regression. A 95% confidence interval and p-value < 0.05 show a statistically significant association. The data were analysed using STATA 15. iv University of Ghana http://ugspace.ug.edu.gh Results A total of 333 pregnant women at 36 weeks or more gestational age were studied. The mean age of the women was 27.56, standard deviation was ± 6.20 and the range was 18-45 years. IPTp-SP coverage among pregnant women during the current pregnancy was 99.4% (irrespective of the number of doses), but only 65.5% received ≥3 doses at the time of the study. Factors such as educational level, receiving information on IPTp-SP from ANC staff, attending ANC in the first trimester were significant in the unadjusted regression model but not significant in the multiple logistic regression models. Pregnant women who had their first SP dose at 24 weeks or more were 8.5 times more likely to take less than 3 doses of SP (AOR: 8.46, 95% CI: 2.03 - 35.21). Conclusion This study suggests that the use of IPTp-SP among pregnant women in Prestea Huni-Valley is below the national target for three or more doses. The knowledge level on IPTp-SP among women pregnant 36 weeks of gestation and above is inadequate. Gestational age of first SP dose significantly associated with the uptake of SP. Refresher training on IPTp-SP policy for ANC staff and continuous education within the community on the benefits of IPTp is required. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT ............................................................................................................. iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES ........................................................................................................................ x LIST OF ABBREVIATIONS ........................................................................................................ xi CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background to the Study ....................................................................................................... 1 1.2 Problem Statement ................................................................................................................ 3 1.3. Justification of the Study ...................................................................................................... 4 1.4 Objectives .............................................................................................................................. 5 1.4.1. General Objective .......................................................................................................... 5 1.4.2. Specific Objectives ........................................................................................................ 5 1.5 Research Questions ............................................................................................................... 6 CHAPTER TWO ............................................................................................................................ 8 LITERATURE REVIEW ............................................................................................................... 8 2.0 Introduction ........................................................................................................................... 8 2.1 Malaria in Pregnancy Global Vision and Targets ................................................................. 8 2.2 Ghana's Target for Control of Malaria in Pregnancy ............................................................ 8 2.3 New WHO Recommendations for Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine ............................................................................................................................ 9 2.4 Factors Influencing Intermittent Preventive Treatment Uptake in Pregnancy .................... 10 2.4.1 Socio-demographic factors influencing uptake of Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine in Pregnancy ............................................................................. 10 2.5 Antenatal Attendance Characteristics Influencing Uptake of IPTp-SP. ............................. 11 2.5.1. Gestational age at first Antenatal Care visit ................................................................ 11 2.5.2 Gestational age at first dose of SP ................................................................................ 12 2.5.3 Number of Antenatal Care Visits ............................................................................ 12 vi University of Ghana http://ugspace.ug.edu.gh 2.6 Knowledge of Pregnant women on Intermittent Preventive Treatment .............................. 13 2.7 Attitude of Health Staff ....................................................................................................... 13 2.8 Health Delivery System Challenges the Uptake of IPTp-SP .............................................. 14 CHAPTER THREE ...................................................................................................................... 15 METHODS ................................................................................................................................... 15 3.0 Introduction ......................................................................................................................... 15 3.1 Study Design ....................................................................................................................... 15 3.2 Study Area ........................................................................................................................... 15 3.3 Study Population ................................................................................................................. 18 3.3.1 Inclusion Criteria .......................................................................................................... 19 3.3.2 Exclusion Criteria ......................................................................................................... 19 3.4 Sampling Technique ............................................................................................................ 19 3.5 Sampling Size Determination......................................................................................... 20 3.5 Study Variables ................................................................................................................... 20 3.6 Data Collection Methods and Instruments .......................................................................... 22 3.8 Quality Control .................................................................................................................... 24 3.9 Pretesting ............................................................................................................................. 24 3.10 Ethical consideration ......................................................................................................... 25 CHAPTER FOUR ......................................................................................................................... 27 4.0 RESULTS ............................................................................................................................... 27 4.1 Socio-demographic Characteristics of Pregnant Women Attending ANC in Prestea Huni- Valley District ........................................................................................................................... 27 4.2 Use of ANC Services by Respondents in Prestea Huni-Valley District ............................. 29 4.3 Practices at ANC on IPTp-SP in Prestea Huni-Valley District ....................................... 31 4.4 Knowledge on SP among Respondents ............................................................................... 32 4.5 Association between Background Characteristics of Pregnant Women and less than 3 or more SP Uptake ......................................................................................................................... 35 4.6 Association Between the Use of ANC Services by Respondents and Less Than Three SP Uptake ....................................................................................................................................... 36 4.7 Factors Associated with less than three SP Uptake............................................................. 37 4.8 Observations at Antenatal Clinics ....................................................................................... 41 CHAPTER FIVE .......................................................................................................................... 43 5.0 DISCUSSION ......................................................................................................................... 43 vii University of Ghana http://ugspace.ug.edu.gh 5.0 Introduction ......................................................................................................................... 43 5.1 Knowledge Level of Pregnant Women in Prestea Huni-Valley District ............................ 43 5.2 Uptake of IPTp-SP among Pregnant women in Prestea Huni-Valley ................................. 44 5.3 Factors Associated with Uptake of IPTp-SP ....................................................................... 45 CHAPTER SIX ............................................................................................................................. 47 CONCLUSION AND RECOMMENDATIONS ......................................................................... 47 6.0 Introduction ......................................................................................................................... 47 6.2.1 Ante-natal Clinic........................................................................................................... 47 6.2.2 Public Health Intervention ............................................................................................... 48 6.2.3 Community Level ......................................................................................................... 48 REFERENCES ............................................................................................................................. 49 APPENDICES .............................................................................................................................. 55 Appendix 1: Consent Form ....................................................................................................... 55 Appendix 2: Questionnaire........................................................................................................ 58 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: Definition of Study Variables ...................................................................................... 22 Table 4.1 Socio-demographic Characteristics of Pregnant Women Attending ANC in Prestea Huni-Valley District...................................................................................................................... 28 Table 4.2 Use of Antenatal Services by Respondents in Prestea Huni-Valley District ................ 30 Table 4.3 Practices at ANC on IPTp-SP in Prestea Huni-Valley District .................................... 32 Table 4.4 Knowledge Level on SP among Pregnant Women Attending ANC in Prestea Huni- Valley District ............................................................................................................................... 33 Table 4.5 Association Between Background Characteristics of Pregnant Women and less than 3 or more SP Uptake ........................................................................................................................ 35 Table 4.6 Association between the Use of ANC Services by Respondents and less than Three or more SP Uptake ......................................................................................................................... 37 Table 4.7 Factors Associated with less than three SP Uptake ...................................................... 39 Table 4.8: Observation at ANC Facilities ..................................................................................... 42 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1 Conceptual framework showing the Uptake of IPTp-SP by Pregnant Women ............ 6 Adopted and modified from Antwi (2010) ..................................................................................... 6 Figure 3.1 Geographical Map of the Prestea Huni-Valley District showing health facilities ...... 18 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ANC - Antenatal Care CWC - Child Welfare Clinic DHS - Demographic Health Survey DOT - Direct Observe Therapy GHS - Ghana Health Service IPT - Intermittent Preventive Treatment IPTp –SP - Intermittent Preventive Treatment of Malaria in Pregnancy with Sulphadoxine Pyrimethamine ITN - Insecticide Treated Net MDG - Millennium Development Goal MICS - Multiple Indicator Cluster Survey MIP - Malaria in Pregnancy MOH - Ministry of Health NMCP - National Malaria Control Programme PMI - President's Malaria Initiative SP - Sulphadoxine Pyrimethamine WHO - World Health Organization xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background to the Study Malaria in pregnancy has become a major public health problem. It mostly attacks pregnant women and the unborn babies (WHO, 2013). The canker of malaria and its tolling effects on individuals and the economy of endemic countries cannot be underestimated. An evaluated US$ 2.7 billion was used in controlling and eliminating malaria worldwide in 2016 (World Malaria Report 2016). About 74% of investments were spent in the WHO African Region, followed by the WHO Regions of South-East Asia (7%), the Eastern Mediterranean and the Americas (each 6%), and the Western Pacific (4%)(World Malaria Report 2016). Plasmodium falciparum is the most prevailing malaria parasite in sub-Saharan Africa. It accounted for about 99% of malaria cases in 2016. Outside Africa, Plasmodium Vivax is the main parasite in the WHO Region of the Americas, accounting for 64% of malaria cases, and above 30% in the South-East Asia and 40% in the Eastern Mediterranean Regions. Pregnancy increases a woman’s susceptibility to malaria. This increased risk have also been attributed to the immunological, hormonal and physiological changes in pregnancy (Takem & D’Alessandro 2013). The reduced immunity may result in the risk of acute and severe clinical disease as well as more frequent episodes (WHO, 2011). In addition, sickle cell anaemia, adolescent pregnancies, and HIV/AIDS co-infection also increases the susceptibility of a woman to Malaria during pregnancy (Ministry of Health, 2006). It is predominant in the first pregnancy, accounting for recurrent malaria infection. Severe infection which causes anaemia or cerebral malaria are partly responsible for a higher risk of mortality. Effective interventions exist to break this cycle, such as promotion and use of insecticide-treated nets (ITNs), intermittent preventive treatment of malaria 1 University of Ghana http://ugspace.ug.edu.gh during pregnancy (IPTp), and appropriate case management through prompt and effective treatment of malaria in pregnant women. WHO endorses the use of antimalarial drug (Sulphadoxine- Pyrimethamine) to guard against malaria in pregnant women. This recommendation applies to areas in Africa with modest and elevated spread of malaria. It was observed as of 2016 that 36 countries in Africa have embraced the strategy to provide 3 or more doses of IPTp-SP to pregnant women. The headway in observing this strategy has slightly increased. In 2016, 23 African countries reported on IPTp-SP use among eligible pregnant women. The coverage for the proposed 3 or more doses of IPTp-SP was 19%.In 2015, an estimated 18% of pregnant women received the recommended dose, an increase 5% over 2015 coverage (13%) (WHO, 2017).In Africa, mortality due to malaria infection was the third among the reproductive age women in 2015. Malaria continues to take a great toll on pregnant women and their babies. Effective strategies have been put in place to preserve highly susceptible population over the past few years. It is hyper endemic in Ghana and among expectant mothers. Malaria accounts for 17.6% of OPD attendance, 13.7% of admissions and 3.4% of maternal deaths. Malaria in pregnancy is a priority area in the Roll Back Malaria strategy. The control of malaria during pregnancy, therefore, depends on both preventing the infection and clearing parasitaemia when the disease occurs. This makes malaria the most common cause of hospital attendance in all age groups. An evaluated yearly economic loses of over US$ 5 million from the cost of therapy, from work and school absenteeism (GHS, 2015). Studies have revealed that factors such as parity, educational level, knowledge on IPTp, simplified messages on IPTp, frequent ANC visit , availability of SP, staff attitude, staff training among others can influence the uptake of IPTp-SP.The IPTp noticeably lags behind other malaria control interventions (WHO 2017). 2 University of Ghana http://ugspace.ug.edu.gh Malaria in pregnancy increase risk of maternal death because it leads to severe anaemia. The incidental effect are in two fold (i) higher risk of infant mortality and disability due to low birth- weight in new born (ii) stillborn and growth retardation. The approved approach for control of malaria in pregnancy are; proper management of cases, sleeping under insecticide-treated bed nets (ITNs) and the use of Sulphadoxine-Pyrimethamine for intermittent preventive treatment. Antenatal care provides a substantial occasion to motivate pregnant women to use IPTp (GHS, 2015).The SP is given to pregnant women at no cost through Directly Observed Treatment (DOT) supervised by a skilled health staff in both public and private antenatal facilities. This strategy was used to achieve 90% of expectant mothers receiving at least two doses of Sulphadoxine- Pyrimethamine (SP) in the second and third trimesters of pregnancy (GHS, 2015). Currently, the IPTp policy by WHO recommends that the first dose of IPTp-SP be given early in the second trimester. The successive doses be given at least one month apart up to the time of delivery without harm (WHO, 2012). The purpose of the study is to examine factors associated with the use of IPT-SP among pregnant women in Prestea Huni-Valley District. The result of the study will contribute to literature and inform development of interventions to increased uptake of IPT-SP in pregnant women. 1.2 Problem Statement Malaria in pregnancy has become a major Public health problem with devastating effects on pregnant women, the unborn babies and economies of countries in sub-Sahara Africa. In 2015, malaria in pregnancy was estimated to have been responsible for more than 400,000 cases of maternal anaemia and 15% of maternal deaths globally (WHO, 2016). Several studies have concluded that malaria in pregnancy is associated with small-for-gestational-age babies and maternal anaemia is a risk factor for stillbirths and preterm births. Intermittent preventive treatment 3 University of Ghana http://ugspace.ug.edu.gh with Sulphadoxine-Pyrimethamine (SP) is a full therapeutic course of antimalarial medicine given to pregnant women at routine antenatal care visit regardless of whether the recipient has malaria or not. WHO recommends IPTp-SP for all pregnant women, starting as early as possible from the second trimester, at each scheduled antenatal care visit until the time of delivery provided the doses are given at least one month apart. According to Ghana Demographic and Health Survey 2014, nearly 4 in 10 pregnant women received 3 or more doses of Sulphadoxine-Pyrimethamine (Fansidar) during Antenatal Care (ANC). In 2016, 36.7% of pregnant women who attended antenatal clinics were administered with IPTp-SP 3 dose (GHS Annual Report, 2016) which is below the national target of 80%. The Western region recorded the least among all other regions in Ghana with 32% of pregnant women receiving IPTp- SP 3 dose (DHIMS 2, 2016). The coverage for IPTp-SP 3 doses in Prestea Huni-Valley District was 27% in 2016 (DHIMS 2, 2016). Therefore, this study seeks to determine the factors that lead to low uptake of IPTp-SP among pregnant women at Prestea Huni- Valley district. 1.3. Justification of the Study The main interventions used to prevent malaria in pregnancy (MIP) in Ghana are the use of Intermittent Preventive Treatment (IPTp) in pregnancy (IPTp) and Insecticide Treated Nets (ITNs) (National Malaria Control Programme (NMCP) 2016). These have been proven to contribute to a reduction in Low Birth Weight (LBW) and neonatal mortality compared with newborn babies of mothers with no such protection (Eisele et al, 2012). There have not been any documented studies specifically in any part of Western Region to determine factors influencing the uptake of Intermittent Preventive Treatment (IPTp) using Sulphadoxine Pyrimethamine (SP). 4 University of Ghana http://ugspace.ug.edu.gh This study seeks to provide evidence-based research information regarding factors associated with low uptake of SP-IPTp among pregnant women at Prestea Huni-valley. The results of this study will help fill the knowledge gap on the uptake of IPT. It will also enable top-level management to formulate targeted interventions to increase the uptake of SP-IPTp in the district. Recommendations from this study may also help to give an insight into how the authorities or health policy makers could put in place strategies to improve the quality of care, which will also enhance uptake of SP-IPTp in the district. The increase in uptake of IPTp-SP would help reduce maternal anaemia, stillbirths and low birth weight and its corresponding maternal and neonatal deaths. 1.4 Objectives The objectives of this study are divided into general and specific as follows: 1.4.1. General Objective To assess knowledge, uptake and factors associated with uptake of Intermittent Preventive Treatment in pregnancy (IPTp) among pregnant women in the Prestea Huni Valley District. 1.4.2. Specific Objectives The specific objectives of the study are: 1. To assess the knowledge level of pregnant women on IPTp-SP. 2. To determine the uptake of SP- IPTp among pregnant women 3. To examine factors associated with uptake of IPTp-SP. 5 University of Ghana http://ugspace.ug.edu.gh 1.5 Research Questions 1. What is the level of knowledge of pregnant women on IPTp-SP in Prestea Huni-Valley district? 2. What is the level of uptake of IPTp-SP among pregnant women above 36 weeks at Prestea Huni-Valley district? 3. What are the factors that affect the uptake of SP-IPTp among pregnant women in Prestea Huni-Valley District? 1.6 Conceptual Framework for the Study Socio- d emographic Individual Factors: factors: Knowledge, cultural Age, educational level, belief, attitude, economic status, parity, information religion Uptake of IPTp-SP by pregnant women Progr am-related Factors: Health System Factors: Support, Stock-out, poor staff attitude, access to health Dr ug policy facility Figure 1.1 Conceptual framework showing the Uptake of IPTp-SP by Pregnant Women Adopted and modified from Antwi (2010) 6 University of Ghana http://ugspace.ug.edu.gh Figure 1 is the conceptual framework showing factors that influence uptake of intermittent preventive treatment for pregnant women. The main determinants are socio-demographic factors, individual factors, program-related factors, and health system factors. These factors interact with each other to determine the outcome variable (uptake of IPTp-SP by pregnant women). For example, higher educational level, high economic status is positively correlated with woman uptake of IPTp (Exavery et al., 2014). Knowledge of IPTp and how much information pregnant women have also influence the uptake of IPTp. Health system factors such as access to the health facility, stock-out, poor providers' attitude and level of knowledge of the health provider influence the uptake of IPTp among pregnant women. Research shows that programme-related factors such as support and drug policy are associated with the uptake of IPTp among pregnant women (Thiam, Kimotho, & Gatonga, 2013). 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter reviews relevant studies and papers affiliated to malaria in pregnancy and Intermittent Preventive Treatment (IPTp) using Sulphadoxine Pyrimethamine (SP).The review focused on studies carried out and relevant documents to fully understand the determinants of SP uptake, methods use for undertaking the studies and key findings. 2.1 Malaria in Pregnancy Global Vision and Targets Malaria is a major public health concern with the most affected being in sub-Saharan Africa. The Global Technical Strategy for Malaria 2016-2030 seeks to guide the future direction of malaria control and elimination. The goal is to reduce malaria mortality rates and case incidence globally, using 2015 as a baseline (214 million new cases, 438 000 malaria deaths), at least 40% by 2020, at least 75% by 2025 and 90% by 2030 (WHO, 2016). This calls on the health sector and the non- health sectors to strengthen their engagement in the fight against malaria and build a global partnership towards the achievement of the sustainable development goal that all sectors accountable and truly leaves no one behind. This is to ensure a Malaria-Free World. Malaria will then not be considered as the major cause of mortality in the world. 2.2 Ghana's Target for Control of Malaria in Pregnancy The National Malaria Control Program, (NMCP) and the health sector in Ghana has a goal to reduce malaria morbidity and mortality burden by 75%, using 2012 as a baseline, by 2020. One of the objective to attain this is to protect at least 80% of the population at risk with effective malaria prevention intervention by 2020. 8 University of Ghana http://ugspace.ug.edu.gh All pregnant women will receive at least three doses of SP or more using the directly observed therapy in the antenatal clinics. Ghana has adopted the WHO updated recommendation on IPTp-SP in pregnancy. 2.3 New WHO Recommendations for Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine To prevent malaria in pregnancy, WHO recommends the use of IPT for malaria in pregnancy with Sulphadoxine Pyrimethamine in countries with high malaria transmission (World Malaria Report, 2013) SP is an anti-malarial drug, which has been found to be safe to use in pregnancy and has no adverse effects on the foetus (WHO, 2012). It prevents the adverse effects of malaria on the pregnant woman and the unborn child. Such adverse effects include maternal anaemia, placental infection, low birth -weight, clinical malaria, fetal anaemia and neonatal death. It is highly cost- effective for both preventions of malaria in pregnancy and reduction of neonatal mortality in areas with moderate or high malaria transmission (Sicuri et al., 2010). IPT is the regime of a comprehensive curative treatment dose of an efficacious anti-malaria drug at arranged intervals during pregnancy (Kibusi, Kimunai, & Hines, 2015). WHO (2000) recommended the use of a minimum of two doses of SP to prevent malaria in pregnancy. This should be administered in the second trimester and not later than thirty – six weeks before delivering. In 2012, WHO updated recommendations on the use of IPTp-SP. There was a result of a meta- analysis of seven trials evaluating IPTp-SP. The findings of which proved that three or more doses of IPTp-SP were associated with higher mean birth weight than two doses of IPTp-SP. The relative risks reduction for low birth- weight was estimated to be 20% (95% Cl 6-31) and absolute risk of reduction of 33 per 1000 births (95% CL 10-52). This effect was consistent across a number of SP- 9 University of Ghana http://ugspace.ug.edu.gh resistant levels. There was less placental malaria associated with three plus dose group. There was no difference in serious adverse events between the two groups (Kayentao, Garner, Macarthur, & Luntamo, 2013). The current recommendation is that every effort be made to expand the use of IPTp-SP in Africa especially areas with high malaria infection. This should be part of antenatal care, where it is encouraged at pregnant women make about 8 visits. Three tablets of SP equivalent to 1500mg/75mg should be given as Directly Observed Therapy (DOT).SP should not be given to pregnant women taking co-trimoxazole prophylaxis. There is an increased risk of adverse events. For its efficacy as antimalarial to be maintained, WHO recommends the administration of folic acid at a dose of 0.4mg daily as such dose may be safely used in addition to SP. Folic acid at a daily dose above or equal to 5mg given in combination with SP prevent its efficacy as antimalarial. It can be administered on an empty stomach or with food (WHO, 2012). Thirty-six African countries have adopted the policy (WHO, 2017). 2.4 Factors Influencing Intermittent Preventive Treatment Uptake in Pregnancy 2.4.1 Socio-demographic factors influencing uptake of Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine in Pregnancy Studies conducted on IPTp-SP have shown that socio-demographic factors tend to influence the level of uptake of IPTp-SP. According to the World Malaria Report 2014, factors such as age, having no formal education or living in the rural area were significantly associated with pregnant women not receiving IPTp-SP. Kisibu et al., (2015) also reported that pregnant women having first or second child had higher odds of completing recommended IPTp-SP dosages than those who have had two or more children. Also being married or living with a partner were significantly associated 10 University of Ghana http://ugspace.ug.edu.gh with higher uptake of IPTp-SP than women who never married or divorced. According to Exavery et al, (2014) women with secondary or higher educational level almost twice as likely as those who had never been to school to have received higher IPTp-SP doses during pregnancy (RRR=1.93; 95% CI=1.04-3.56). It was identified in a study conducted in rural Western Kenya that lower level of education and being single were factors associated with IPTp-SP uptake (Ouma et al., 2007). These findings were not consistent with that reported by Marchant et al.., (2008). In their study, none of the socio-demographic factors were associated with uptake of IPT p-SP. 2.5 Antenatal Attendance Characteristics Influencing Uptake of IPTp-SP. 2.5.1. Gestational age at first Antenatal Care visit The timing of IPTp-SP administration may depend on the gestational age at which the pregnant woman register at the ANC. A late registration will reduce the number of administration of IPTp- SP. A study conducted by Anchang-Kimbi et al., (2014) to evaluate the determinant of ANC clinic attendance and uptake of IPTp-SP among pregnant women, reported that a higher proportion of women(62%) who made the first visit during the third trimester received only one dose of IPTp-SP. Meanwhile, women who made early first ANC attendance were more likely to receive two or more doses of IPTp-SP (OR=0.4; 95%CL=0.2-0.7). These findings were contrary to that reported by Gross et al., (2011). In their study, they found out that facility and policy factors are greater barriers to IPTp-SP coverage than women's timing of ANC attendance. Exavery et al., (2014) reported that timing of ANC initiation is significantly important in determining the extent of IPTp-SP uptake among pregnant women in Tanzania, early ANC initiation was associated with a higher likelihood of higher uptake of IPTp-SP. Similar findings by Kibusi et al (2015) revealed that having first ANC 11 University of Ghana http://ugspace.ug.edu.gh visit the third trimester contributed to low uptake of IPTp-SP than those having the first visit in the first trimester. 2.5.2 Gestational age at first dose of SP Gestational age at which pregnant women take the first dose of IPTp-SP differ from country to country. This is based on recommendations from their national guidelines. In Ghana, the national policy on IPTp-SP administration recommends that IPTp-SP should be taken at sixteen weeks of gestation, whiles in Tanzania first dose is administered between 20-24 weeks of gestation. Mail and Kenya also recommend uptake of the first dose of SP at sixteen weeks. However, Mozambique's national guidelines recommend the first dose of SP is given at twenty weeks (Gomez et al., 2014). However irrespective of the time for initiation of the first dose, early uptake of the first dose may be necessary to achieve complete schedule doses of IPTp-SP. Anders et al., (2008) reported that early uptake of IPTp-SP was found to be hampered by factors such as insufficient SP drug stocks or women's individual preferences. An additional factor could also be an unexpectedly high proportion of women attending an antenatal clinic before recommended gestation for the administration of the first dose of IPTp-SP. 2.5.3 Number of Antenatal Care Visits Frequent visits to the ANC centers have resulted in higher uptake of IPTp by pregnant women. Ndyomugyenyi et al. (2010) conducted a study to determine the relationship between ANC visits and coverage of IPTp-SP, and barriers to IPTp-SP. Of the four hundred and fifty study participants, only 21.2% made four or more visits. Access to two or more doses of IPTp-SP increased with the number of ANC visits. The finding from this study also revealed that 28.9% of study participants made two or more ANC visits, giving them the opportunity to have received two or more doses of IPTp-SP, however, these pregnant women did not receive IPTp-SP. They identified SP-stock outs 12 University of Ghana http://ugspace.ug.edu.gh and irregular ANC attendance as barriers to uptake of IPT-SP. They concluded that frequent visits to ANC do not seem to ensure access to IPTp-SP in the presences of other barriers. Another study conducted by Olorunda et al., (2013) in Nigeria to determine the relationship of NAC attendance and IPTp-SP uptake and also factors that could affect IPTp uptake reported that 62.2% of study participants made four or more visits to the ANC and adherence to IPTp-SP increased with the number of ANC visits. Adherence to IPTp-SP was significantly higher among those who made four or more visits compared to those who made less than four visits. Others studies have also shown that frequent visits to the antenatal car do not necessarily translate into full coverage with IPTp-SP (Ouma et al., 2007, Kiwuwa & Mufubenga, 2008). 2.6 Knowledge of Pregnant women on Intermittent Preventive Treatment A major determinant of IPT use was found to be the knowledge about the prophylaxis. Therefore, uptake of IPT can be improved significantly if backed health education on the benefits of taking SP and complication of malaria in pregnancy (Amaron et al., 2012). According to Antwi (2010), there is a correlation between doses between IPTp-SP taken and the knowledge of pregnant women. The best source of knowledge about IPTp is through antenatal clinics where health workers educate pregnant women. Having knowledge on IPTp will acquaint the pregnant woman on the benefit to attend antenatal regularly to enable her to receive SP, hence improve IPT intake. 2.7 Attitude of Health Staff Fear of safety of the drug on the part of the service provider has an effect on the uptake of IPTp (Amoran et al., 2012). In the Bosotwe district of Ghana, a study found that 99% of respondents were satisfied with the attitude of providers and were motivated to return for subsequent visits. Fetus positively influenced SP uptake women as reported in the study (Antwi, 2010). In a 13 University of Ghana http://ugspace.ug.edu.gh systematic review of health systems barrier to IPT coverage, Thiam, Kimotho, and Gatonga (2013) found lack of client-provider relationship as a challenge that hindered IPTp Implementation. 2.8 Health Delivery System Challenges the Uptake of IPTp-SP Some barriers to effective uptake of IPTp-SP have been identified. Systematic review of relevant kinds of literature from Africa indicated that (i) implementation of IPTp policies is hampered by prevailing service delivery barriers, such as long waiting time, long distance to health facilities and poor service provider/client relations and (ii) drug stock-outs and poor management of information and supply chain knowledge specifically availability of SP. Focusing on health system barriers which are necessary for a successful IPTp policy implementation (Thiam, Kimotho, & Gatonga, 2013). A study carried out by Amoran et al., (2012), identified barriers such as SP stock out and lack of health education of the pregnant women, and that solving these challenges will increase IPTp-SP uptake. Diala, Pennas, Marin, & Belay, (2013) also identified some system-based challenges. These were stock-out of SP, lack of provider’s knowledge of IPTp-SP protocol coupled with individual women's belief and lack of understanding of IPT. All these accounted for low uptake and adherence to IPTp-SP. 14 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.0 Introduction The method section of presents details of how the study was carried out, from the design stage to data collection through to data analysis. It gives details on the study design, location, and variables of interest, sample size determination, data collection, and instrument for data collection, processes and analysis of data, quality control and ethical considerations. 3.1 Study Design This study employed a cross-sectional design, facility-based, using one-on-one interviewer- administered structured questionnaires adapted from Antwi (2010) to determine factors associated with low uptake of SP-IPTp intervention among pregnant women at Prestea Huni-Valley District. 3.2 Study Area The study was conducted at the Prestea Huni -Valley District in Western Region of Ghana. Prestea- Huni Valley District is situated in the centre of Western Region with Bogoso as the administrative capital. The district shares boundaries with the Tarkwa-Nsuaem Municipal Area to the South, Wassa Amenfi East District to the North, Wassa Amenfi West District to the West and Mpohor Wassa East District to the East. It has a land size of about 1,376 sq. km and has an estimated population of 197,969 as at 2017 projected from the 2010 census with 50,093 women in fertile age and 7,919 expected pregnancies. The District is divided into 7 sub-districts for effective healthcare delivery. The sub-districts are Prestea, Bogoso, Aboso, Huni-Valley, Himan, Awudua and Insusiding. There are twenty-seven health facilities in the district of which nineteen are owned by the government, one by Seventh Day Adventist mission and seven privately owned. All the sub- 15 University of Ghana http://ugspace.ug.edu.gh districts provide basic emergency obstetric and newborn care with only the district hospital providing comprehensive emergency obstetric and newborn care. In all, 23 facilities in the district provide antenatal care. The district has 2 medical officers, 42 midwives, and 56 community health nurses. In 2016, a total of 6,982(97%) pregnant women were registered in the ANC clinic in the district and 48.4% made four ANC visits. For the purpose of this study, the following three health facilities were selected: Prestea Hospital Prestea Hospital is the district hospital for Prestea Huni-Valley. It is located in Prestea sub-district, with a catchment area population of 38,579 in 2016 projected from 2010 census. Women in their fertile Age (WIFA) (15-49 years) were 9,259 .It serves as the referral point for other health centers and Community- based Health Planning and Services (CHPS) in the District and beyond. Services offered include; Antenatal Care, postnatal care, delivery, family planning, laboratory, Ear Nose and Throat, physiotherapy, ophthalmic care, mental health among others. There are 2 medical officers, 22 midwives and 10 supporting staff at the maternity unit. The 2016 annual report indicated that there were 1,700 ANC registrants. Aboso health Centre Aboso health Centre is one of the health Centres built by European Union in 1976.It is situated on the outskirt of Aboso township on the Aboso Huni-Valley road. Aboso sub-district had a population of 26,915 in 2016, with WIFA of 6,460.The facility provide a 24-hour maternity services. The facility is headed by a Physician Assistant with five midwives at the maternity unit. In 2016, Aboso Health Centre recorded a total of 960 ANC registrants. 16 University of Ghana http://ugspace.ug.edu.gh Bogoso Health Centre Bogoso Health Centre is located in the District capital of Prestea Huni-Valley, Bogoso.The catchment area had a population of 35,887 as a sub-district.WIFA population for 2016 was 8,613. The facility provide a 24-hour maternity services. The facility is headed by a Physician Assistant with 10 midwives at the maternity unit. Bogoso Health Centre recorded 1,350 ANC registrants in2016. The major occupation of the people is mining. There are multi-national companies engaged in the mining of gold. These companies which are mostly manned by elite whites employ Ghanaians from all over the country and other Africans. Apart from mining, other activities are agriculture, banking, trading, and others are also undertaken in the district. There are many religious groupings in the district; these include Christians, Moslems, and Traditional Believers. The study was be conducted at Prestea Government hospital, Bogoso and Aboso health centers. 17 University of Ghana http://ugspace.ug.edu.gh Figure 3.1 Geographical Map of the Prestea Huni-Valley District showing health facilities Source: Prestea Huni-Valley Health Directorate, Annual Report 2016. 3.3 Study Population The study population consists of registered pregnant women who were 36 weeks old and above attending ANC at the time of the study. 18 University of Ghana http://ugspace.ug.edu.gh 3.3.1 Inclusion Criteria Eligible clients for this study were pregnant women attending ANC with 36 weeks of gestation and above, aged 18 years and above, and those who had made at least two visits and agreed to participate in the study. 3.3.2 Exclusion Criteria Pregnant women who satisfied the inclusion criteria but could not speak or hear (deaf and dumb), have a mental health condition, referred from different facilities, absent at the time of the study and those who refused to give their consent were excluded from the study. 3.4 Sampling Technique The district hospital and 2 health centers were selected purposively because they recorded the lowest IPTp coverage in the district in 2016. Pregnant women who were 36 weeks and above and have attended 2 or more ANC visits on the period of the interview were recruited using simple random sampling technique. This was done by first obtaining the ANC register for the year and the records of all pregnant women met the inclusion criteria were extracted. Then numbers were assigned to them which was later entered into Microsoft excel 2013 and a list of random numbers were generated. All pregnant women identified with the randomly generated numbers were contacted for an interview and those who consented to part-take were met on their day of ANC visit and interviewed. Pregnant women who refused to part-take in the study were replaced with newly generated numbers. To avoid resampling participants, the name and folder number of pregnant women were interviewed cancelled from the duplicated ANC attendants list after the interview. 19 University of Ghana http://ugspace.ug.edu.gh 3.5 Sampling Size Determination According to the District Health Information Management System II (DHIMS 2) Report (2016), 27% of pregnant women received IPT 3 in Prestea Huni-Valley District. The sample size was calculated using the 73% of pregnant women who did not receive IPT 3. The sample size was determined using the Cochran's (1977) formula. n= z2pq 𝑒2 n = minimum required sample size z = z-score at 95% confidence level=1.96 p = proportion of pregnant woman who did not receive IPT3 to be 73% (DHIMS, 2016) q = 1- p = 1 - 0.73= 0.27 e = degree of precision, set at 5% = 0.05 Substituting, N = (1.96)2×0.73×0.27 0.05×0.05 = 3.8416×0.73×0.27 0.05×0.05 = 302.87 approximately 303 303 was increased to 333 to make up for a possible 10% non-response rate. 3.5 Study Variables The study variables are categorized into dependent and independent variables. 20 University of Ghana http://ugspace.ug.edu.gh Dependent variable The dependent variable measured in this study is the uptake of SP-IPTp by pregnant women defined as doses of SP received during pregnancy. This variable was measured as counts and later dichotomized into less than three uptake of SP and three or more uptake of SP with less than three uptake of SP as the outcome of interest for this study. Respondents’ overall knowledge was assessed by asking the four questions on SP and marks were allocated to their responses. Correct answers were awarded 1 mark while wrong one attracted zero point and the total score for the four questions were computed and grouped into No (zero points), inadequate (1-2 points) and adequate(3-4 points). Independent variables Client-related factors/Socio-demographic characteristics: sex, age, educational level, marital status, occupation, Health-related factors: stocks-out, poor staff attitude, access to a health facility Program-related factors: support, drug policy Table 3.1 below shows the study variables and their scale of measurement. 21 University of Ghana http://ugspace.ug.edu.gh Table 3.1: Definition of Study Variables Variables Operational definition Scale of measurement Independent variables Socio-demographic factors Sex Male or female Nominal Age Age at as last birthday Continuous Educational level No formal education primary Ordinal JHS, SHS/ vocational, Tertiary Marital status Single, married, divorced, Nominal widow Occupation Formal or informal work Nominal Knowledge of the use of A degree of information on Ordinal IPTp-SP the use of IPTp-SP Cultural beliefs and taboos Existing cultural beliefs of Nominal respondents at the time of study Awareness of IPTp-SP Low (unaware) or high Ordinal (aware)-level of awareness Access to IPTp-SP Availability of IPTp-SP in the Nominal Prestea government hospital Program-related factors Program support Availability of drugs Ordinal Dependent variable Uptake of IPTp-SP Doses of SP received during Discrete pregnancy 3.6 Data Collection Methods and Instruments Data were collected by administering structured questionnaires, through a face to face interview for respondents. The data collection was monitored by the researcher in order to ensure research 22 University of Ghana http://ugspace.ug.edu.gh procedures are adhered to by the research team. The questionnaire consists of three parts: (1) socio- demographic characteristics (2) Respondent’s awareness and practice of IPTp-SP at the ANC. (3) Respondent’s knowledge on IPTp-SP. Questionnaires were administered by the researcher and research assistants. In each selected facility the purpose of the study was first explained to the participants and a written consent from the participants sought before the questionnaire was administered. The questionnaire consists of close and open-ended questions. There was also yes or no for ticking, and selecting a response of choices among a number of possible alternatives. An observational check was also done at all the ANC facilities to establish the availability of SP.IPTp protocol, training manual, presence of posters of IPTp, daily health talk etc. by visiting and inspecting all the ANC facilities during their ANC sections and requesting for some of the items which were not on display. The data collection was done in June 2018. 3.7 Data processing and Analysis The data extracted from the responses in the questionnaire was coded and entered into the Excel spreadsheet (Microsoft office, 2016). The data was cleaned and exported into STATA 15 for analysis. Descriptive statistics on categorical variables were reported using frequencies and percentages while that of the continuous variable were presented with averages and standard deviation or median with interquartile range depending on the distribution of the data. Association between categorical independent variables and the outcome variable (uptake of IPTp) was examined using the chi-squared\Fishers’ exact test of independence while Welch t-test was used to compare means of continuous variable between the two categories of the outcome variable. Test of normality of continuous variables will done using the skewness and kurtosis test. Binary logistic 23 University of Ghana http://ugspace.ug.edu.gh regression model was used to assess the effect of the various independent variables on the outcome variable. All statistical test were done at 5% significance level. The results obtained from the various analyses are presented in tables. 3.8 Quality Control To ensure quality, prior to data collection, three research assistants, with a minimum qualification of West African Secondary School Certificate (WASSCE), were engaged to assist on administering questionnaire. They were trained in a two day workshop. The focus was on the research, how to address issues during data collection, and how to effectively make use of data collection instruments. They were also trained on procedures required for efficient data collection, the techniques of questionnaire administration and ethical guidelines. Each research assistant was given a sheet containing all necessary basic field protocols. Additionally, the researcher monitored and supervised data collection to ensure research procedures were being adhered to by the research team. Each research assistant was assigned to one facility. Furthermore, all completed questionnaires from the field were reviewed daily and on-the-spot feedback provided where needed. Every completed questionnaire was coded with unique ID numbers to ensure they can easily be traced. All completed questionnaires during the survey were then signed by research assistants and safely transferred to the researcher for data entry. The information in each questionnaire was entered into STATA version 15 for analysis. 3.9 Pretesting The questionnaires were pretested at Wassa Akropong Government Hospital, in Wassa Amenfi East District which has similar characteristics as the Prestea Huni-Valley District. The necessary corrections were made before use. 24 University of Ghana http://ugspace.ug.edu.gh 3.10 Ethical consideration The study proposal was approved by the Ghana Health Service Ethical Review Committee (GHSERC045/02/18). Permission was obtained from Western Regional Health Directorate, Prestea Huni-Valley District Health Directorate and the selected facilities (Prestea Hospital, Bogoso Health Centre, and Aboso Health Centre). Reasons for conducting the study was clearly explained to all respondents and consent obtained. Respondents were told that they have the right not to participate in the study or opt out during the course of the study and their decision will be respected. Privacy and confidentiality were ensured by not asking sensitive questions that will inflict any emotional injury on respondents. Respondents were assured of anonymity. To ensure this, identification codes were used to disguise a respondent's original identity. Data was secured with a password on a computer. Completed questionnaires will be burnt after being kept under lock and key for five years. Participant consent Every respondent was approached to obtain consent prior to participation. Before participants were given a questionnaire, each was given a consent form to read and sign. Individuals who cannot read, the purpose of the study was explained to them and if they accepted to partake in the study, their thumbprints were taken. Confidentiality All respondents were given assurance that any information they provide will be used solely for academic purposes and their confidentiality was assured. Their names or personal identification information will not be published in any report. Information collected would not be shared with anybody who is not part of the study. 25 University of Ghana http://ugspace.ug.edu.gh Risk and Benefit Respondents were assured that the research will not cause them any harm since the procedures involved in the study is non-invasive. Except that their precious time that they will use to fill out the questionnaire, there are no direct benefits or risk of participation of the study. The results will be used to improve knowledge about IPTp and services in the health facilities in the district and beyond. Compensation There was no compensation for participating in this study. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS 4.0 INTRODUCTION This chapter presents the results of the study. The chapter consists of seven sections. 4.1 Socio-demographic Characteristics of Pregnant Women Attending ANC in Prestea Huni- Valley District This study recruited 333 expectant mothers attending ANC at Bogoso Health Centre (n=111, 33.3%), Prestea Gov't Hospital (n=122, 36.6%) and Aboso Health Centre (n=100, 30.0%). The respondents were aged between 18 and 45 years inclusive. The average age was 27.6 years. The proportion of married women was 71.2% (n=237). The average parity was 2 children with more than half (n=176, 52.9%) of them having 1 to 2 children. More than one-third (n=141, 42.3%) of them completed junior high school with about 61.0% (n=203) of them being employed. Christianity was the predominant (n=237, 71.2%) religion among the study respondents. It takes most of the respondents a maximum of half an hour to travel to their various health facilities. Table 4.1 gives details of the background characteristics of the study respondents. 27 University of Ghana http://ugspace.ug.edu.gh Table 4.1 Socio-demographic Characteristics of Pregnant Women Attending ANC in Prestea Huni-Valley District Frequency Percent Age in years : Mean ± SD 27.56 ± 6.20 ≤ 19 33 9.9 1 20-24 94 28.23 25-29 76 22.82 30-34 82 24.62 ≥35 48 14.41 Health facility Bogoso Health Centre 111 33.33 Prestea Gov't Hospital 122 36.64 Aboso Health Centre 100 30.03 Marital status Married 237 71.17 Divorced 14 4.20 Single 69 20.72 Cohabitation 13 3.90 Parity Mean ± SD 2.28 ± 1.74 No child 40 12. 01 1 – 2 176 52.85 3 – 4 82 24.62 5 – 8 35 10.51 Educational level No 43 12.91 Primary 71 21.32 JHS 141 42.34 SHS/Vocational 51 15.32 Tertiary 27 8.11 Occupation Formal 34 10.21 Self employed 203 60.96 Unemployed 96 28.83 Religion Christianity 237 71.17 Islam 92 27.63 Traditional 4 1.20 SD: Standard deviation 28 University of Ghana http://ugspace.ug.edu.gh Table 4.1 Cont’: Socio-demographic Characteristics of Pregnant Women Attending ANC in Prestea Huni-Valley District Frequency Percent T ravel time to hospital Less than or equal to 30minutes 200 60.06 31 minutes to 1hour 83 24.92 More than 1hour 50 15.02 Belief on against SP Yes 117 35.10 No 225 64.90 Belief Baby will be big to deliver normal 36 34.62 Baby will be aborted 51 49.04 Discomfort/body Weakness 14 13.46 Drug will be vomited 3 2.88 SD: Standard deviation 4.2 Use of ANC Services by Respondents in Prestea Huni-Valley District Table 4.2 gives information on the use of ANC services of the study respondents. Averagely, the respondents first visit ANC after 15.7 weeks of pregnancy. Most (n=79, 58.5%) of them gave the reason of not having any problem with their pregnancy so decided to start the ANC after 16 weeks. Almost all the (n=331, 99.4%) respondents had been given SP at the time of the study with less than 10% (n=21) receiving it before 16 weeks of pregnancy. Those who took ≥3 doses were more than half (n=218, 65.5%). In most (n=323, 97.6%) cases the medication is taken by the respondents under the supervision of the midwives at the ANC. About nine of every ten (n=301, 90.9%) selected respondents received SP medication free of charge. Among those who received SP three tablets were taken per each dose of SP by all the respondents (n=331, 100%). The proportion of respondents with less than three SP uptake was 34.5% (n=115). 29 University of Ghana http://ugspace.ug.edu.gh Table 4.2 Use of Antenatal Services by Respondents in Prestea Huni-Valley District Frequency Percent Time of First ANC visit Mean ± SD 15.68 ± 6.59 First trimester 140 42.04 Second trimester 169 50.75 Third trimester 24 7.21 Reason for attending ANC after 16 weeks Long distance to ANC 9 6.67 Did not have money for transport 32 23.70 Did not have a problem with the pregnancy 79 58.52 Was seen by a herbalist/ spiritualists 7 5.19 Did not know she was pregnant 5 3.70 Wanted to terminate the pregnancy 1 0.74 Shyness 2 1.48 Given SP Yes 331 99.40 No 2 0.60 Gestation age when given SP(n=331) Before 16 weeks 21 6.34 16 - 19 weeks 115 34.74 20 - 23 weeks 108 32.63 ≥ 24 weeks 87 26.28 Medicine taken in front of a midwife(n=331) Yes 323 97.58 No 8 2.42 Pay for medicine(n=331) Yes 30 9.06 No 301 90.94 Tablets swallow per visit(n=331) Three 331 100.00 SD: Standard deviation 30 University of Ghana http://ugspace.ug.edu.gh Table 4.2 Cont’: Use of Antenatal Services by Respondents in Prestea Huni-Valley District Frequency Percentage Number of times medicine was taken None 2 0.60 One 44 13.21 Two 69 20.72 Three 104 31.23 Four 72 21.62 Five 33 9.91 Six 4 1.20 Seven 5 1.50 4.3 Practices at ANC on IPTp-SP in Prestea Huni-Valley District Information on SP medication was given to about six of every ten selected respondents. The majority (n=201, 60.7%) of the respondents were not asked to stop taking folic acid alongside SP. Less than one-tenth (n=30, 9.0%) of the respondents were ever told of a shortage of SP of this, 30.8% of them are given a prescription to buy SP due to the shortage. Those who actually bought the drug were seven (87.5%). Generally, the respondents described staff attitude at the ANC as positive (good to excellent). Though 74.2% (n=247) of the respondents were advised to visit ANC on a monthly basis if not sick, 78.1% of them adhered. 31 University of Ghana http://ugspace.ug.edu.gh Table 4.3 Practices at ANC on IPTp-SP in Prestea Huni-Valley District Frequency Percentage Advised to stop taking Folic acid while taking SP(n=331) Yes 130 39.27 No 201 60.73 Educated on medicine given(n=331) Yes 208 62.84 No 123 37.16 Ever told of Shortage of medicine(n=333) Yes 30 9.01 NO 303 90.99 Given prescription to buy SP due to a shortage(n=30) Yes 8 26.70 No 22 73.30 Bought prescribed SP(n=8) Yes 7 87.50 No 1 12.50 Staff attitude at ANC(n=333) Poor 18 5.41 Good 148 44.44 Very good 123 36.94 Excellent 44 13.21 Times told by the midwife to attend ANC if not sick(n=333) Every Week 35 10.51 Every two Weeks 42 12.61 Monthly 247 74.17 Every two Months 9 2.70 Times attended ANC when not sick(n=333) Every week 9 2.70 Every two weeks 26 7.81 Monthly 260 78.08 Every two months 38 11.41 4.4 Knowledge on SP among Respondents In assessing respondents knowledge on SP, more than half (n=226, 67.9%) of them knew the use of SP medication. However less than half (n=138, 41.4%) knew when a pregnant woman is supposed 32 University of Ghana http://ugspace.ug.edu.gh to start SP uptake. For time interval between takings of each dose, 67% (n=223) of the respondents had adequate knowledge. Majority (n=218, 65.9%) of the study respondents experienced no side effect after taking SP. Less than a third (n=78, 23.4%) of the study respondents knew the possible consequences of not taking SP on mother. Overall, about one-third (n=127, 38.1%) of the respondents had adequate knowledge on SP. Table 4.4 Knowledge Level on SP among Pregnant Women Attending ANC in Prestea Huni- Valley District Frequency Percentage Know the use of SP No 107 32.13 Yes 226 67.87 What is SP used for? To prevent malaria in pregnancy 226 67.87 To protect a mother and unborn baby and mother from 14 4.20 any sickness To treat malaria 15 4.51 For deworming 1 0.30 Help unborn baby to grow 1 0.30 Don’t know 76 22.82 Knows starting time for taking SP No 195 58.56 Yes 138 41.44 When is pregnant woman supposed to start taking SP? Before 16 weeks 11 3.30 16 weeks/ quickening 138 41.44 20 weeks 15 4.51 24 weeks and above 4 1.20 Don’t know 165 49.55 Knows interval between each dose No 110 33.03 Yes 223 66.97 33 University of Ghana http://ugspace.ug.edu.gh Table 4.4 Cont’ Frequency Percentage What is the interval between each dose? 2 weeks 5 1.50 4 weeks 223 66.97 8 weeks 8 2.40 Do not know 97 29.13 Did you experience any side effect after taking SP? No 218 65.86 Yes 113 34.14 What was your experience of taking SP? No side effect 218 65.86 Abdominal crumps 5 1.51 A headache 6 1.81 Palpitation 1 0.30 Dizziness 12 3.63 Body weakness 47 14.20 Nausea/ vomiting 42 12.69 Knows possible effect on the mother if SP is not taken No 255 76.58 Yes 78 23.42 What is the possible effect on the mother if SP is not taken? Malaria 36 10.81 Abortion 32 9.61 Anaemia 4 1.20 Stillbirth 3 0.90 Small baby after delivery 7 2.10 Do not know 251 75.38 Source of information Radio 11 3.32 Television 34 10.27 ANC staff 248 74.92 IPTp posters 8 2.42 Other pregnant women/friends 9 2.72 No information 21 6.34 Overall Knowledge level No knowledge 44 13.21 Inadequate knowledge 162 48.65 Adequate knowledge 127 38.14 34 University of Ghana http://ugspace.ug.edu.gh 4.5 Association between Background Characteristics of Pregnant Women and less than 3 or more SP Uptake Table 4.5 shows the test of association between demographic characteristics of study respondents and less than three SP uptake. Education of respondents was the only factor significantly associated with less than three SP uptake (χ2 =22.5, p<0.001). Thus, the respondents with higher education had lesser proportions of less than three doses than those with lower educational level. Table 4.5 Association Between Background Characteristics of Pregnant Women and less than 3 or more SP Uptake No(%) Yes(%) Chi-square p-value Age: Mean ± SD 27.77 ± 6.36 27.17 ± 5.88 0.85 0.393 ¥ Health facility 2.04 0.360 Bogoso Health Centre 78(70.27) 33(29.73) Prestea Govt Hospital 79(64.75) 43(35.25) Aboso Health Centre 61(61) 39(39) Marital Status 0.73 0.866 Single 47(68.12) 2 2(31.88) Cohabitation 8(61.54) 5(38.46) Married 155(65.4) 82(34.6) Divorced 8(57.14) 6(42.86) Level of Education 2 2.51 < 0.001*** No Formal education 3 1(72.09) 1 2(27.91) Primary 35(49.3) 36(50.7) JHS 87(61.7) 54(38.3) SHS/Vocational 40(78.43) 11(21.57) Tertiary 25(92.59) 2(7.41) Occupation 5.39 0 .068 Sector Worker 2 8(82.35) 6(17.65) Self Employed 132(65.02) 71(34.98) Unemployed 58(60.42) 38(39.58) SD: Standard deviation, *p<0.05, **p<0.01, ***p<0.001, %: row percentage, ¥: p-values estimated from Welch t-test 35 University of Ghana http://ugspace.ug.edu.gh Table 4.5 Cont’: Association Between Background Characteristics of Pregnant Women and less than 3or more SP Uptake Less than three or more SP uptake No(%) Yes(%) Chi-square p-value Religion 0.72 0.699 Christianity 152(64.14) 8 5(35.86) Islam 63(68.48) 29(31.52) Traditional 3(75) 1(25) Belief 1.99 0 .371 Baby will be too big 27(75.00) 9(25.00) Baby will be aborted 34(68.00) 16(32.00) Other specify 157(63.56) 90(36.44) Travel time to Facility(Minutes) 1.01 0.604 ≤ 30 135(67.5) 65(32.5) 31 – 60 51(61.45) 32(38.55) > 60 32(64) 18(36) Parity 0 .26 0.967 No child 25(62.5) 15(37.5) 1 – 2 117(66.48) 59(33.52) 3 – 4 53(64.63) 29(35.37) 5 – 8 23(65.71) 12(34.29) SD: Standard deviation, *p<0.05, **p<0.01, ***p<0.001, %: row percentage, ¥: p-values estimated from Welch t-test 4.6 Association Between the Use of ANC Services by Respondents and Less Than Three SP Uptake Chi-square test shows an association between less than three SP uptake and education received on SP, the frequency of ANC attendance, and source of information, gestation age of first ANC visit (P<0.05). Details of the test are shown in Table 4.6 36 University of Ghana http://ugspace.ug.edu.gh Table 4.6 Association between the Use of ANC Services by Respondents and less than Three or more SP Uptake Less than three SP uptake No(%) Yes(%) Chi-square p-value Gestation age of first ANC visit 20.15 <0.001*** First trimester 101(72.14) 39(27.86) Second trimester 111(65.68) 58(34.32) Third trimester 6(25.00) 18(75.00) Educated on SP 9.7 4 0.002** Yes 150(72.12) 58(27.88) No 68(55.28) 55(44.72) The attitude of ANC staff 1.9 8 0.577 Poor 13(72.22) 5(27.78) Good 91(61.49) 57(38.51) Very good 84(68.29) 39(31.71) Excellent 30(68.18) 14(31.82) how offend attend ANC 14. 54 0.002** Every week 8(88.89) 1(11.11) Every two weeks 14(53.85) 12(46.15) Monthly 180(69.23) 80(30.77) Every two months 16(42.11) 22(57.89) Source of information 0.001***§ Radio 7(63.64) 4(36.36) Television 27(79.41) 7(20.59) ANC staff 171(68.95) 77(31.05) IPT posters 3(37.50) 5(62.50) Other pregnant women and friends 2(22.22) 7(77.78) No information 8(38.10) 13(61.90) Ever told of a drug shortage 0.44 0.509 Yes 18(60.00) 12(40.00) No 200(66.01) 103(33.99) *p<0.05,**p<0.01, ***p<0.001, %: row percentage, §: p-value estimated from Fishers’ exact test. 4.7 Factors Associated with less than three SP Uptake The multiple logistics regression analysis shows that time of first SP uptake was the only significant factors affecting SP uptake (Table 4.7). 37 University of Ghana http://ugspace.ug.edu.gh Respondents who had their first dose of SP at gestation age of 16 weeks had 22% lesser odds of receiving IPTp-SP less than 3 doses compared to those who started SP uptake at less than 16 weeks (AOR: 0.78, 95% CI: 0.19-3.16). However, respondents who received their first SP dose at gestation age of 20 weeks had 1.7 times higher odds of receiving IPTp-SP less than 3 compared to those who had their first dose before 16 weeks. (AOR: 1.72, 95% CI: 0.43-6.82). Additionally, respondents who had their first SP dose at gestation age of 24 weeks and above had 8.5 times higher odds of receiving less than 3 doses of 1PTp-SP compared to those who had their before 16 weeks. Dependent variables such as educational level, gestational age of first visit, receiving education on IPTp-SP were significantly related to less than 3 SP uptake in the unadjusted model. However, in the multiple logistic regression model they were not significant (p>0.05). 38 University of Ghana http://ugspace.ug.edu.gh Table 4.7 Factors Associated with less than three SP Uptake Unadjusted Adjusted UOR 95% CI p-value AOR 95% CI p-value Age 0.98 0.95 - 1.02 0.403 0.98 0.91 - 1.05 0.501 Health facility attended 0.362 0.062 Bogoso Health Centre ref Ref Prestea Govt. Hospital 1.29 0.74-2.23 2.29 0.96 - 5.46 Aboso Health Centre 1.51 0.85-2.68 3.23 1.16 - 9.00 Marital status 0.867 0 .859 Married ref R ef Divorced 1.42 0 .48-4.22 0.91 0.19 - 4.35 Single 0.88 0.5-1.57 0.76 0.33 - 1.76 Cohabitation 1.18 0.37-3.73 1.54 0.31 - 7.76 Level of education < 0.001*** 0.149 None ref Ref Primary 2.66 1.18-5.99 1.79 0 .61 - 5.27 JHS 1.6 0.76-3.39 0.95 0.33 - 2.75 SHS&Vocational 0.71 0.28-1.82 0.72 0.2 - 2.62 Tertiary 0.21 0.04-1.01 0.21 0.03 - 1.42 Parity 0.967 0.773 No child ref Ref 1 – 2 0.84 0.41-1.71 1.55 0.55 - 4.33 3 – 4 0.91 0.42-2 1.14 0.3 - 4.32 5 – 8 0.87 0.34-2.24 1.36 0.24 - 7.64 Religion 0.7 0.557 Christian Ref Ref Islam 0.82 0.49-1.38 0.76 0.38 - 1.53 Traditional 0 - 11.76 0.6 0.06-5.82 0.17 How long does it take from your home to facility? 0.605 0.951 <=30 mins ref Ref 31 mins to 1hour 1.3 0.77-2.22 1.12 0.55 - 2.32 > 1hour 1.17 0.61-2.24 1.04 0.44 - 2.47 AOR: Adjusted odds ratio, UOR: Unadjusted odds ratio, CI: Confidence interval, *p<0.05, **p<0.01, ***p<0.001 39 University of Ghana http://ugspace.ug.edu.gh Table 4.7 cont’: Factors Associated with less than three SP Uptake Unadjusted Adjusted UOR 95% CI p-value AOR 95% CI p-value Time of first visit <0.001* ** 0.285 1st trimester ref Ref Second trimester 1.35 0.83-2.2 1.27 0.64 - 2.53 3rd trimester 7.77 2.87-21.02 2.80 0.78 - 10.03 Time of Frist dose <0.001* of SP ** <0.001*** < 16 weeks ref Re f 16 weeks 0.74 0.22- 2.46 0.78 0.19 - 3.16 20 weeks 1.95 0.61-6.24 1.72 0.43 - 6.82 ≥24 weeks 8.5 2.62-27.58 8.46 2.03 - 35.21 Did you pay for the medicine? 0.479 0.613 Yes ref Re f No 0.76 0.35- 1.63 1.31 0.46 - 3.72 Education about the medicine 0.002** 0.786 Yes ref Re f No 2.09 1.31- 3.34 1.12 0.49 - 2.56 Medicine not available 0.510 0.854 Yes ref Ref No 0.77 0.36-1.67 1.10 0.4 - 3.01 Attitude of the of the stuff at ANC 0.5785 0.441 Poor ref Ref Good 1.63 0.55-4.81 0.97 0.22 - 4.16 Very good 1.21 0.4-3.62 1.03 0.24 - 4.51 Excellent 1.21 0.36-4.07 2.26 0.41 - 12.36 How often you attend ANC? 0.003** 0.085 Every week ref ref Every two weeks 6.86 0.75-62.96 10.42 0.58 - 188.17 Monthly 3.56 0.44-28.9 4.05 0.27 - 61.63 Every two months 11 1.25-96.95 9.10 0.53 - 155.89 AOR: Adjusted odds ratio, UOR: Unadjusted odds ratio, CI: Confidence interval, *p<0.05, **p<0.01, ***p<0.001 40 University of Ghana http://ugspace.ug.edu.gh Table 4.7 cont’: Factors Associated with less than three SP Uptake Unadjusted Adjusted UOR 95% CI p-value AOR 95% CI p-value Information on SP 0.002** 0.110 Radio ref ref Television 0.45 0.10-2.00 0.51 0.08 - 3.08 ANC staff 0.79 0.22-2.77 0.66 0.14 - 3.16 IPT posters 2.92 0.44-19.23 2.41 0.18 - 32.16 Other pregnant women/friends 6.13 0.83-45.02 7.95 0.77 - 81.87 0.363 No information 2.84 0.63-12.89 1.78 0.25 - 12.42 Yes 0.46 0.29-0.74 0.70 0.32 - 1.52 Take SP 0.02 4* 0.8 43 No ref re f Yes 0.58 0.36- 0.93 0.93 0.44 - 1.97 SP interval 0.00 2** 0.0 87 No ref re f Yes 0.47 0.29- 0.75 0.52 0.25 - 1.1 Any negative experience with SP 0.612 0.186 No Ref re f Yes 1.13 0.7-1 .82 1.62 0.79 - 3.34 Perceived side effect 0.1 69 0.6 94 No Ref re f Yes 0.73 0.46- 1.15 0.86 0.42 - 1.78 AOR: Adjusted odds ratio, UOR: Unadjusted odds ratio, CI: Confidence interval, *p<0.05, **p<0.01, ***p<0.001 4.8 Observations at Antenatal Clinics Observational check was done on availability of SP.IPTp protocol, training manual, presence of posters of IPTp, daily health talk etc. in the three health facilities where the study was conducted. It was observed that no health facility had National IPTp protocol and IPTp training manual for referencing. Two facilities had adequate SP in stock at the time of the visit. According to the staff, the shortages were due to inadequate supply of SP from the Regional Medical Stores and improper logistics management. 41 University of Ghana http://ugspace.ug.edu.gh Only one of the facility had posters of IPTp displayed on the walls. All facilities visited gave a health talk before the start of the day’s work. However, none included malaria in pregnancy and IPTp for the quarter on their planned heath talk itinerary. During the visit, it was observed that DOT was practiced in all the facilities. Also all the three facilities visited correctly recorded SP into the maternal health records and the ANC register. Both filled and empty monthly midwife’s returns were available with column for IPTp filled. There was no adverse events forms for SP available in all the three facilities visited (Table 4.8). Table 4.8: Observation at ANC Facilities Observations at ANC Facilities Number of Facilities (n=3) Availability of IPTp national protocol 0 Availability of SP at ANC 2 Availability IPTp training manual 0 Presence of posters of IPTp on the wall 1 Health education itinerary for the quarter includes 0 IPTp Daily health talk at ANC 3 Practice of DOT 3 Availability of water for DOT 3 SP is recorded in the maternal record 3 SP is recorded in the ANC register 3 Presence of Adverse event forms for SP 0 Presence of monthly midwife’s returns form 3 42 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION 5.0 Introduction This chapter discusses the results of the study. The discussions covers: Knowledge level of pregnant women in the Prestea Huni-Valley, Uptake of IPTp-SP and Factors associated with uptake of IPTp-SP. 5.1 Knowledge Level of Pregnant Women in Prestea Huni-Valley District The findings from this study indicated that approximately 70% of respondents had adequate knowledge of IPTp-SP use which was a significant determinant of uptake of optimal doses in the Prestea Huni-Valley District. About 41.4%( of respondents also had adequate knowledge on when to start taking IPTp-SP in this study. This study result is not different from results of other studies which reported that knowledge of IPTp is significantly related to uptake of IPTp (Amoran et al., 2012; Antwi, 2010; Exavery et al., 2014). Nankwanga and Gorette (2008) reported a low level of knowledge of IPTp among pregnant women in Kampala which resulted in low coverage of IPTp. This implies that health education among pregnant women on IPTp will improve their knowledge level and increase uptake. However, mothers’ knowledge of the consequence of malaria in pregnancy was low, 24.6%. This is in line with findings by Enato et al., (2007). This low knowledge on the outcome of malaria in pregnancy has a grave consequences on both the mother and the foetus. Meanwhile, the association between perceived knowledge of the consequence of malaria in pregnancy was not significant in previous studies (Chepkemoi Ng’etich Mutulei, 2013). This implies that there is not enough information about the IPTp-SP programme at the facility level. It could also mean that midwives 43 University of Ghana http://ugspace.ug.edu.gh administering the drug may not be knowledgeable enough about the programme or they might have assumed that pregnant women knew about the programme. This suggest that the best source of knowledge about IPTp is through antenatal care where health workers educate pregnant women. The overall knowledge for respondents on IPTp-SP in this study is low (n=127, 38.14%). 5.2 Uptake of IPTp-SP among Pregnant women in Prestea Huni-Valley This study found that 99.4%(n=331) of the respondents received at least one dose of SP in the Prestea Huni Valley. This is consistent with a similar study by Antwi (2010) in the Bosomtwe district which found that 95% of pregnant women received at least one dose of IPTp. Pregnant women who received at least two doses of IPT was 86% and 65.5% received 3 or more doses of IPTp. The coverage of 65.5% is lower than the current national target of 80% for IPTp 3 or more doses. The 65.5% coverage at least 3 doses in this study is higher than the 39% of 3 or more doses uptake reported in the Ghana Demographic and Health Survey (GSS, 2015A). The WHO Report in 2016 show that an estimated 19% of eligible pregnant women received 3 or more doses of IPTp in Africa. The Ghana Health Service Annual Report for 2016 suggests that approximately 60% of pregnant women received 3 or more doses of IPTp. A similar study was conducted by Ibrahim (2015) in Sunyani Municipality. She found that over 71% of pregnant women received 3 or more doses of IPTp. This is consistent with the findings of this study. Comparing ANC records with respondents’ self-report unveiled no major variability in the uptake of IPTp-SP.However, efforts are needed to get the national target of 80%. 44 University of Ghana http://ugspace.ug.edu.gh 5.3 Factors Associated with Uptake of IPTp-SP There was a significant relationship between uptake of IPTp and respondents' level of education, source of IPTp-SP information, ANC attendance in the first trimester, early starting of IPTp-SP, counseling on SP and frequent ANC visit. Early initiation of ANC is essential to receiving optimal doses of SP. A woman initiating ANC in the first trimester and making regular visits is likely to receive more doses of SP, provided SP is available and DOT is practiced at the facility. This means that when a pregnant woman initiates ANC early, there will be enough time for her to be counseled on IPTp-SP and other interventions. This study discovered that commencement of ANC in the first 3 months of pregnancy was associated with uptake of 3 or more doses of IPTp-SP. This finding is similar to a study conducted by Anchang-Kimbi et al, (2014) which reported that women who made early ANC attendance were more likely to receive two or more doses of IPTp-SP. These findings were contrary to the results of Gross et al., (2011) study. In their study, they reported that women’s timing of attendance was not significant. This shows the importance of timely initiation of ANC among pregnant women in order to increase their chances of optimal uptake of IPTP-SP and eventually prevent malaria-related health problems. Another key determinant of receiving more doses of SP revealed in the current study was the time of the first dose was received. Receiving the first dose early in the second trimester gave the opportunity for more doses to be taken. The second trimester is the pivot of scheduled ANC visits, which requires the mother to report on a monthly basis. (Olliaro P.L et al, 2008).This study found that majority of the women initiate ANC in the first and second trimesters with a median gestational age of 15 weeks which is equivalent to findings in Bosomtwe district where the median gestational age at first ANC was 16 weeks(second trimester) (Antwi, 2010). 45 University of Ghana http://ugspace.ug.edu.gh Educational level of respondents was significantly associated with 3 or more IPTp uptake (Χ2= 22.5, p<0.001). Thus, the higher the educational level, the more likely it is for a pregnant woman to take the optimal dose of IPTp- SP. This could be due to the fact that education facilitates in making informed decisions, especially on maternal issues. Studies have shown that women who are educated have good health-seeking behaviour and appreciate better the complications associated with pregnancy and childbirth (Hill et al., 2013a). Counseling on IPTp-SP by ANC staff or source of information on IPTp-SP from ANC staff affected uptake. This study suggests that for many of the respondents (74.9%), service providers at the ANC were their main source of information and knowledge of IPTp. But this study noticed that not one of the facilities had training manual or protocol on IPTp-SP to refer to. Additionally, there was no planned health talk schedule that includes IPTp-SP. Hence, will have an impact on the kind of information pregnant women will receive during ANC visits. A similar finding was reported by Antwi (2010) in the Bosomtwe District. Maternal status, place of residence, party and age had no remarkable effect on uptake of IPTp-SP in this study. However, a study conducted by Kibusi, Kimunai, & Hines (2015) found that being married, age (30-39 years), having 2 or more children were associated with higher uptake of IPTp- SP. 46 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.0 Introduction This chapter draws a conclusion from the findings and makes recommendations to inform policy interventions and areas for further research. 6.1 Conclusions This study suggests that the coverage of IPTp-SP uptake amidst pregnant women in Prestea Huni- Valley is high (65.5%) compared to the 27% coverage for IPTp-SP 3 doses stated in DHIMS 2, (2016) for Prestea Huni-Valley District. Nevertheless, this is far beneath the national target of 80% for 3 or more doses. Results of the multiple logistic regression analysis indicate that gestational age at first SP was the major predictor to SP uptake. More research especially qualitative study is needed to explain concealed misconception that prevent the optimal uptake of IPTp-SP. 6.2 Recommendations 6.2.1 Ante-natal Clinic 1. Refresher training for ANC staff should be organized to upgrade their knowledge, address gaps and deficiencies in the IPTp- SP policy. 2. Health staff should include topics on IPTp-SP in their planned health education itinerary. 3. Proper logistics management to ensure availability of SP at the facilities at all times is highly recommended. 47 University of Ghana http://ugspace.ug.edu.gh 4. In-charges at ANC and District Health Management Team (DHMT) should ensure staff adhere to IPTp-SP protocols and standards. 6.2.2 Public Health Intervention 1. The National, Regional and District Health Promotion units of Ghana Health Service should develop health promotion packages to explain the benefits of IPTp-SP, early and regular ANC attendance. 2. National Malaria Control Program (NMCP) and Ghana Health Service should ensure provision of guidelines and protocols to all health facilities. 3. Provision of posters on IPTp-SP at all health facilities should be done by the District Health Promotion Unit. 4. National Malaria Control Program should ensure availability and continuous supply of SP to all facilities. 6.2.3 Community Level 1. Involvement of all stakeholders on crusade that give information on the risk of malaria during pregnancy and the benefits of IPTp-SP. 2. There should be advocacy on female education by all stakeholders. 48 University of Ghana http://ugspace.ug.edu.gh REFERENCES Amoran, O.E. Ariba, A.A, & Iyaniwura, C.A. (2012). Determinants of intermittent preventive treatment of malaria during pregnancy (IPTp) utilization in a rural town in western Nigeria. Reproductive health, 9(1) 12. Anchang–Kimbi, J.K. Achidi, E.A, Apinjoh, T.O, Mugri, R.N., Fru Chi, H, Tata, R preventive treatment during pregnancy (IPTp) and malaria parasitaemia at delivery. Malaria Journal, 13(1), 162. Anders, K. Marchant, t., Chambo, P., Mapunda, P., & Reyburn, H. (2008). Timing intermittent preventive treatment for malaria during pregnancy and the implications of current policy on early uptake in north-east Tanzania. Malaria Journal, 7, 79. Antwi, G.D. (2010). Factors influencing the uptake of intermittent preventive treatment of Malaria in pregnancy in the Bosomtwe District of Ghana, Kumasi, Ghana: Kwame Nkrumah University of science and technology. Bouyou-Akotet, M.K. Mawili-Mbounmba, D.P., & Kombila, M. (2013). Antenatal care visit attendance, intermittent preventive treatment and bed net use during pregnancy in Gabon. BMC Pregnancy and childbirth, 13(1), 52 Choka, C.A. & Onwujekwe, O.E. (2012). Low coverage of intermittent preventive treatment for malaria in Nigeria: demand-side influences. Malaria journal, 11(1), 82. Cochran, W.G. (1977). Sampling techniques. New York: John Wiley and Sons, Inc. WG Cochran1963Sampling techinques.New York John Wiley and Sons, Inc. 49 University of Ghana http://ugspace.ug.edu.gh Desai, M., Ter Kuile, F.O, Nostern, F., Mcgready, R., Asakoa, K, Brabin, B., & Newman, R.D. (2013). Epidemiology and burden of malaria in pregnancy. The Lancet infectious Diseases, 7(2), 93-104. District health Information Management system (DHIMS 2) (2016) Data Prestea Huni-Valley District. Diala, C.C., Pennas, T., Marin, C., & Belay, K.A. (2013). Perceptions of intermittent preventive treatment of malaria in pregnancy (IPTp) and barriers to adherence in Nasiriya and Cross River States in Nigeria. Malaria Journal, 12(1), 1. Enato, E. F. O., Okhamafe, A. O., & Okpere, E. E. (2007). A survey of knowledge, attitude and practice of malaria management among pregnant women from two health care facilities in Nigeria. Acta Obstetricia et Gynecologica Scandinavica, 86(1), 33–6. http://doi.org/10.1080/00016340600984670. Exavery, A., Mbaruku, G., Mbuyita, S., Makemba, A., Kinyonge, I.P., & Kweka, H. (2014). Factors affecting uptake of optimal doses of sulphadozine-pyrimethanime for intermittent preventive treatment of malaria in pregnancy in six districts of Tanzania. Malaria Journal, 12(1), 22. Garner, P., Gulmezoglu, A. M. (2006). Drugs for preventing malaria in pregnant women. Cochrane Database Systematic Reviews (4) Ghana Health Service. (2016).GHANA HEALTH SERVICE 2016 ANNUAL REPORT Ghana Statistical Service (GSS) (2014). Ghana Demographic and health Survey Accra, Ghana GSS, GHS and ICF Macro. 50 University of Ghana http://ugspace.ug.edu.gh Gómez-Díaz, E. Rivero, A. Chandre, F & Corces, V.G. (2014). Insights into the epigenomic landscape of the human malaria vector Anopheles gambiae. Front Genet. 5: 277 Gross K, Alba S, Schellenberg J, Kessy F, Mayumana I, & Obrist B. (2011). The combined Effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania. Malaria J. 21; 10: 140. Hill, J., Dellicour,S., Bruce, J., Ouma, P., Smedley, J., Otieno, P.,……..& Webster, J (2013). Effectiveness of Antenatal clinics to Deliver Intermittent Preventive treatment and Insecticide Treated Nets for the Control of malaria in pregnancy in Kenya. PloS ONE, 8(6). Ibrahim, H. (2015). Factors Influencing Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy using Sulphadoxine Pyrimethamine in the Sunyani Municipality, Ghana. University Of Ghana, Legon. Kayentao, K. Gerner, P. Macerthur, J. & Lutamo, M. (2013). Intermittent preventive Therapy for malaria during pregnancy using 2vs 3 or More Doses of Sulfadoxine- pyrimethamine and Risk of Low Birth Weight in Africa. JAMA, 309(6), 594-604. Kibusi, S.M. Kimunai, E. & Hiness, C.S. (2015). Predictors for uptake if intermittent preventive treatment of malaria in pregnancy (IPTp) in Tanzania. BMC PUBLIC Health, 15(1), 540. Kibusi, M.S., & Mufubengga, P. (2008). Use of antenatal care, maternity services, intermittent presumptive treatment and insecticide treated bed nets by pregnant women in Luwero district, Uganda, Malaria Journal, 7, 44. 51 University of Ghana http://ugspace.ug.edu.gh Kiwuwa, M.S & Mufubenga, P. (2008). Use of antenatal care, maternity services, intermittent presumptive treatment and insecticide treated bed nets by pregnant women in Luwero district, Uganda. Malaria Journal 7:44 Marchant, T., Nathan, R., Jonse, C., Mponda, H., Bruce, J., Sedekia, Y., & Hanson, K. (2008). Individual, facility and policy level influences on national coverage estimates for intermitted preventive treatment of malaria in pregnancy in Tanzania. Malaria Journal, 7, 260. Menendez, C., Bardaji, A., Sigauque, B., Sanz, S., Aponte, J.J., Mabunda, S., & Alonso, P. L. (2010). Malaria prevention with IPTp during pregnancy reduces neonatal mortality. PloS One: 5(2) e9438. Ministry of health MOH (2014). Anti–Malaria Drug Policy, Ghana Ministry of health (MOH). (2014). Guidelines for case management Ministry of Health. Accra. Retrieved from www.ghanhealthservice.org/includes/upload/publications/GUIDELINESforman.pdf Mpogoro, F.J., Matovelo, D.M. Dosani, A. Ngallabga, S. Mugonon, M. & Maxigo, H.D. (2014). Uptake of intermittent preventive treatment with Sulphadoxine, pyrimethanmine for malaria during pregnancy and pregnancy outcomes: a close sectional study in Geita district, north, western Tanzania. Malaria journal, 13(1) 455. Mpungu.S.K & Mufubenga, P. (2008). Use of antenatal care, maternity services, intermittent presumptive treatment and insecticide treated bed nets by pregnant women in Luwero District, Uganda. Malaria journal 7(1), 44. 52 University of Ghana http://ugspace.ug.edu.gh Mubyazi, G.M, Bygberg, I.C. Magnuussen, P. Olsen, O. Byskow, J. Hanses K.S & Bloch, P. (2008). Propects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers. Malaria journal, 7,135 Ndyomugyenyi, R. & Katamanywa J. (2010). Intermittent preventive treatment of malaria in pregnancy (iptp): do frequent antenatal care visits ensure access and compliance to IPTP in Ugandan rural communities Trans R Soc Trop Med Hyg. 104; 536-540 Odhiambo, D. (2011). Malaria in pregnancy. Eyes on Malaria Ammren Magazine 8th edition pg 32. Olliaro, P.L., Delenne, C.M. Baduiane, M. Olliaro, A. Vaillant M, & Brasseur, P. (2008). Implementation of intermittent preventive treatment in pregnancy with sulphadoxine/pyrimethamine (IPTp-SP) at a district health center in rural Senegal. Malaria journal, 7,234 Olorrunda, D.C & Ajayi, F.C.O. (2013). Do frequent Antenatal care visits ensure Access and Adherance to intermittent preventive Treatment in Malaria in pregnancy in an urban Hospital to South west Nigeria. African journal Biomed Research, 16(3), 153-161, retrieved from www.ajbrui.net (11/11/2017). Ouma, P.O., Van eija, A. M., Hamel, M.J. Sikuku, E. Odhiambo, F. Munguti, K.……… & Slutsker, L. (2017). The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural western Kenya. Tropical Medicine and International Health, 12(8), 953—961. 53 University of Ghana http://ugspace.ug.edu.gh Roll Back Malaria Partnership (RBMP) (2008). Global Malaria Action plan for a malaria free word. WHO, Geneva Switzerland Roll Back Malaria Partnership (RBMP) (2011). Global Malaria Action Plan, Objectives, Targets, Milestones and priorities beyond 2011. WHO Geneva Switzerland. Sicuri E, Bardají A, Nhampossa T, Maixenchs M, Nhacolo A, Nhalungo D……& Menéndez, C. (2010). Cost-effectiveness of intermittent preventive treatment of malaria in pregnancy in southern Mozambique. Public Library of Science PLOS ONE. 15; 5(10) Thiam, S., Kimotho,V., & Gatonga, P. (2013). Why are IPTp coverage targets so elusive in sub- Saharan Africa? A systematic review of health system barriers. Malaria journal, 12(1), 1. Wilson, N. O. Ceesay, F. K., Obed, S. A., Adjei., A.a. , Gyasi, R. K., Rodney, p.,………… & Stiles, J.K. (2011). Intermittent preventive treatment with Sulphadoxine. Journal of Tropical Medicine and Hygiene, 85(1), 12-21 World Health Organisation, (WHO) (2013). Epidemiological approach for malaria control. 2nd edition. Geneva, Switzerland. WHO (2013). WHO Policy Brief for the Implementation of Intermittent Preventive Treatment of malaria in pregnancy using Sulphadoxine. http://www.who.int/malaria /publications /atoz/policy brief iptp policy recommendation/en/ WHO (2012). Updated Who Policy Recommendation for Intermittent preventive Treatment of malaria in pregnancy using Sulphadoxine-Pyrimethamine (IPTp-SP). WHO. (2017). World malaria report. apps.who.int/iris/bitstream/10665/259492/1/9789241565523- eng.pdf?ua=1 54 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix 1: Consent Form Title of research: Factors associated with low uptake of intermittent preventive treatment for Malaria in pregnant women in Prestea Huni-Valley Municipal of Western region. Department: Population, Family and Reproductive Health (PFRH) Email: e.kissiapp@yahoo.com Introduction My name is Elsie Kissi-Appiah and I am a graduate student of the School of Public Health, University of Ghana, Legon, Accra. I am carrying out research in factors associated with low uptake of intermittent preventive treatment for malaria in pregnant women in Prestea Huni-Valley District in Western Region as partial fulfillment of the requirement for a Master’s Degree in Public Health. The purpose of the research is to determine the factors associated with uptake of Sulphadoxine Pyrimethamine (SP) for malaria prevention in pregnancy. The research will help identify challenges with the uptake of SP and also assist health staff on how to improve malaria prevention with Sulphadoxine Pyrimethamine. Question will be used in the interview process. The interview will be centered on how SP was administered and the number of times you took SP administered during last pregnancy. Your background information will also be taken. The interview will take not more than 30 minutes to complete. 55 University of Ghana http://ugspace.ug.edu.gh Your participation in this study is completely voluntary. You have right to refuse participation or withdraw from the study at any time. Should you choose to withdraw, the information you provide will not be used in the study. No penalties or negative consequences will result from your withdrawal. All responses will be treated as confidential as names will place on the question. Questionnaires will also code for data analysis. I hope that you will participate fully. If you want to ask any questions or seek further clarification about the exercise, I would be ready to provide an answer. For further information or clarification on this study, please contact Ms. Elsie Kissi-Appiah (0244666494) or Miss Hannah Frimpong, Administrator, Ghana Health Service Ethical Review Committee, – (0507041223/0243235225). 56 University of Ghana http://ugspace.ug.edu.gh PARTICIPANTS CONSENT FORM I have read the foregoing information/the foregoing information has been read to me or interpreted to me and l fully understand the purpose, and conditions of this research. I understand that I can withdraw from the study at any time without any consequence to me. I have the opportunity to ask questions, and they have been satisfactorily answered. I consent voluntarily to participate in this research, please confirm your participation by signing below. Signature/thumbprint ………………………………………………………………………… Date………………………………………………………………………………………… P.I./research assistant’s name……………………………………………………………… Signature……………………………………………………………………………………… Date…………………………………………………………………………………………… 57 University of Ghana http://ugspace.ug.edu.gh School of Public Health College of Health Sciences University of Ghana Appendix 2: Questionnaire Factors associated with low uptake of intermittent preventive for Malaria in pregnant women in Prestea Huni-Valley District of Western region. QUESTIONNAIRE FOR PREGNANT WOMEN Form number; Sub-district……………… Date of interview; Health facility……………… Code of interviewer; SECTION A; SOCIO-DEMOGRAPHIC CHARACTERISTICS 1 Age of respondent (in completed years) ……… 2. Place of residence … 3. Marital status 1. Married [ ] 2. Divorced [ ] 3.Single [ ] 4.Cohabitation [ ] 4. Level of education 1. No formal education [ ] 2. Primary[ ] 3. JHS [ ] 4. Secondary/ Vocational [ ] 5. Tertiary [ ] 5. How many children do you have? 1. One [ ] 2.Two [ ] 3. Three [ ] 4. Four [ ] 5. Other specify…………. 58 University of Ghana http://ugspace.ug.edu.gh 6. Occupation 1. Formal sector worker[ ] 2. Self-employed [ ] 3. Unemployed [ ] 7. What is your religion? 1. Christianity [ ] 2. Islam [ ] 3. Traditional [ ] 4.Other, specify……………. 8. Is there any belief that prevent you from taking 1 Baby will be too big to deliver drugs (orthodox medicines)? normal [ ] 2. Baby will be aborted. [ ] 3. Other, specify ……………………… 9. How long does it take from your home to 1.<=30 minutes [ ] reach this facility? 2.31 mins to 1hr [ ] 3.> 1hr [ ] Section B: Practice of IPTp at Antenatal Clinic 10. At what stage of your pregnancy did you first ……….. Weeks (confirm from maternal visit the ANC? records). 11. If above 16 weeks, why did you not attend 1.Long distance to ANC [ ] ANC earlier? 2.Did not have money for transport [ ] 3.Did not have any problem with pregnancy [ ] 4.Was being seen by a herbalist[ ] 5.Was being seen by a Spiritualist [ ] 5. Other, specify……………………… 12. Have you been given a medicine like this to 1.Yes [ ] swallow? Please show sample of SP. 2.No [ ] 13. At what stage of your pregnancy did you take 1. Before 16 weeks [ ] 2. 16 weeks [ ] the first dose of the medicine? (Confirm from 3.20 weeks [ ] 4. 24 weeks [ ] 5.Never maternal records). given [ ]6.Above 24 weeks 59 University of Ghana http://ugspace.ug.edu.gh 14. Was the medicine taken under a midwife’s 1.Yes[ ] observation? 2.No [ ] 15. Did you pay for the medicine? 1. Yes [ ] 2. No [ ] 16. How many tablets did you swallow per visit? 1 One. [ ] 2.Two [ ] 3. Three [ ] 17. How many times did you swallow this medicine 1. One [ ] 6.Six[ ] for this pregnancy? 2. Two [ ] 7.Seven [ ] 3. Three [ ] 8.None [ ] 4. Four [ ] 5. Five [ ] (confirm from records ) 18. Did the nurse ask you to stop taking folic acid 1.Yes [ ] whiles taking SP? 2.No [ ] 19. Were you given education about the medicine? 1. Yes [ ] 2. No[ ] 20. Was there any occasion that you were told the 1. Yes [ ] 2.No [ ] medicine was not available? Skip to Q 23 if No. 21. Were you giving prescription to go and buy SP? 1. Yes [ ] 2.No [ ] 22. Did you buy the prescribed SP? 1. Yes [ ] 2. No [ ] 23. How will you rate the attitude of the staff at 1. Poor [ ] 2. Good [ ] ANC? 3. Very good [ ] 4. Excellent [ ] 24. How often are you told by the midwife to attend 1. Every week [ ] 2.Every two ANC if not sick? weeks. 3. Monthly [ ] 4. Every two months [ ] 25. How often to you attend ANC? (Confirm from 1. Every week [ ] 2.Every two records) weeks. 3. Monthly [ ] 4. Every two months [ ] Source of knowledge 26. Where did you get your information on SP 1.Radio [ ] 2.Television [ ] 3.ANC staff from? 4. Other (specify)………… 60 University of Ghana http://ugspace.ug.edu.gh Section C: Knowledge of IPTp- Answers to be provided by respondent 27. What is the medicine (SP) use for? 28. When is a pregnant woman supposed to start taking SP? 29. How many times during pregnancy does a woman have to swallow at ANC? 30. What is the regular interval between each dose? 31. What was your experience of taking SP? 32. What are the possible side effect of taking the SP? 33. What are the possible effect on mother if SP is not taken? 61 University of Ghana http://ugspace.ug.edu.gh Observation at the ANC Unit Name of health facility………………… Date................... Availability of IPTp national protocol Yes [ ] No [ ] Availability of SP at ANC Yes [ ] No [ ] Availability IPTp training manual Yes [ ] No [ ] Presence of posters of IPTp/MIP on the wall Yes [ ] No [ ] Health education itinerary for the quarter includes IPTp/MIP Yes [ ] No [ ] Daily health talk at ANC Yes [ ] No [ ] Practice of DOT observed Yes [ ] No [ ] Availability of water for DOT Yes [ ] No [ ] SP is recorded in the maternal record Yes [ ] No [ ] SP is recorded in the ANC register Yes [ ] No [ ] Presence of Adverse Event forms for SP Yes [ ] No [ ] Presence of monthly ANC data returns form Yes [ ] No [ ] 62 University of Ghana http://ugspace.ug.edu.gh 63